RN Clinical Appeals Nurse

Job Summary

A company is looking for an RN Clinical Appeals Nurse Remote.

Key Responsibilities

• Performs clinical reviews of denied cases and reevaluates medical claims and records
• Applies appropriate criteria for various cases and collaborates with the chief medical officer on denial decisions
• Serves as a clinical resource and provides training to less experienced appeals nurses

Required Qualifications

• At least 3 years of clinical nursing experience, with 1 year in managed care
• Active and unrestricted Registered Nurse (RN) license in the state of practice
• Knowledge of ICD-9, CPT coding, and HCPC
• Familiarity with CMS guidelines and state regulatory requirements
• Experience in claims auditing, QA, or recovery auditing is preferred